Jaundice, with yellow eyes, yellow body, and yellow urine as the main manifestations, is an independent disease in Chinese medicine, with the same meaning as jaundice in Western medicine, roughly equivalent to hepatocellular jaundice, obstructive jaundice, and hemolytic jaundice in Western medicine, with hepatocellular jaundice predominating in clinical practice. The “Yang Huang” and “Yin Huang” identification and treatment system, which was developed in the Yuan Dynasty, has been inherited and still guides clinical practice. However, with the development of medicine in changing times, the understanding of jaundice in Chinese medicine has undergone profound changes in terms of etiology, name, classification and even treatment, prescriptions and medicines. The traditional theory of “yang yellowness” and “yin yellowness” is limited only by the bright color of the face and the dampness, heat and cold of the disease mechanism to distinguish between yang yellowness and yin yellowness, and if this is the standard, there will be “false yin yellowness” and “false yang yellowness If this is used as a criterion, there will be “pseudo-yin yellowness” and “pseudo-yang yellowness”, making the current system of identification unable to cover all jaundice types, lagging behind modern clinical practice and hindering the improvement of clinical efficacy. In response to the existence of non-yin and non-yang jaundice, we proposed the concept of “yin and yang jaundice” and made a preliminary clinical study on its identification and treatment rules, including the use of warming methods to intervene in its treatment, which has achieved significant therapeutic effects. In this paper, we will elaborate on two aspects, hoping to study and discuss with our colleagues so that it can better serve the clinic.
A. Jaundice divided into yin and yang needs to be revised
1, there are limitations in the definition of the traditional division between yang and yin yellowness
Luo Tianyi in the Yuan dynasty in the “Health Baojian. Hair yellow” clearly “Yang in the Yang, wet from the heat, wet heat for the suffering, then Yang yellow; Yang in the lack of wet from the cold, cold wet for the suffering, then Yin yellow. The pathogenesis of Yang Huang is damp-heat obstruction, while that of Yin Huang is spleen-yang deficiency and cold-dampness; the treatment of Yang Huang and Yin Huang is to “clear heat and dampness” and “warm yang and strengthen the spleen” respectively. The system of identification and treatment has been inherited to this day, based on this: the symptoms of Yang Huang are mostly yellow and vivid like orange, dry mouth, bitterness, fever, constipation, red tongue with yellow greasy coating and string pulse and other signs of damp heat or stasis heat; the symptoms of Yin Huang are mostly yellow and dull or like smoke, accompanied by fatigue and fear of cold, white greasy coating and slow pulse and other obvious signs of cold and dampness. This traditional division of jaundice into yin and yang based only on the vividness of the face, the dampness and heat of the disease mechanism, and the cold and dampness of the disease mechanism, is by no means the “gold standard” and has been questioned by many scholars.
(1) The jaundice of yin and yang cannot be distinguished by the brightness of the face alone. A number of scholars believe that some patients with jaundice have a dark face, “the evidence and pulse are all deficient”, which appears to be yin-yellow, but in fact, the evil heat is inside; on the contrary, if you see a bright yellow color, but there is distention and fullness of the abdomen, loss of appetite, loose stools, a pale tongue with a white coating, and a sunken and thin pulse, it is yin-yellow rather than yang-yellow, which confirms that This confirms the saying of the famous contemporary doctor Yu Changrong that “the brilliant orange color is not all yang yellow”;
(2) Only the damp-heat and cold-dampness of the disease mechanism cannot distinguish the yin and yang of jaundice. According to Hu Mianquan, although obscure facial color or fumigation is a frequent symptom of yin-yang, it is commonly seen in yang-yang, where “damp-heat stagnation” or “dampness is better than heat”; fever, yin-yang, is not feverish, but not all are. The symptoms of fever are not all feverish, but not all feverish. Xu Ming [7] believed that yinhuang is developed from yanghuang, and external damp-heat, deficiency and reality are in one, so the existence of damp-heat in yinhuang cannot be categorically excluded. In discussing the pathogenesis of Yin Huang, Pan Xuezhu also believed that the clinical understanding of the pathogenesis of Yin Huang is not very comprehensive and precise, whether from cold and dampness alone or from spleen and Yang alone.
2, Yang Huang and Yin Huang is a progressive relationship
According to the doctrine of yin and yang, yin and yang are a pair of opposing concepts, both are a gradual process of mutual transformation under certain conditions, Yang Huang and Yin Huang is also a gradual process from Yang Huang to Yin Huang. As Cheng Wuji cloud: “There are two yin evidence: one external cold evil, yin meridian suffer from. Or because of eating cold things, hurt the Taiyin meridian; the second is the beginning of the Yang evidence, to cold treatment, cold excessive, change Yang into Yin also. The transformation between Yang yellow and Yin yellow is related to the following factors.
(1) the duration of jaundice is too long “Typhoid” cloud: “jaundice of the disease, when the period of 18 days, the treatment of more than ten days of disease, anti-dramatic for difficult to treat.” Jaundice should be treated early, generally in about ten days of positive anti-evil, treatment and healing for the smooth, if more than ten days of treatment still do not see improvement, and even last more than a month does not go away, the evil is strong and declining, eventually leading to Yang deficiency of cold and dampness within the birth of Yin Huang, treatment difficulties, it is a reverse.
(2) excessive use of bitter-cold or cold drugs “Danxi Xinfa” cloud: “with the medicine of Yin Chen over dose, it is into Yin Huang” so-called “Yang injury and cold worry also hidden and waiting to develop, the so-called injury and a true Yang, then a true cold is also.” If a person with light heat is given a heavy dose of bitter cold, or if the dose of bitter cold is used for too long, the spleen will be damaged and the stomach will be defeated, and the spleen yang will gradually decline, leading to the stagnation of cold and dampness, which will cause the disease to be prolonged and transformed into yinhuang.
(3) Deficiency of spleen yang Qing. Ye Tianshi “clinical evidence guide medical case – Jiang Yu style according to” cloud: “Yin Huang of the work, wet from cold, spleen Yang can not transform wet ……” spleen Yang deficiency is Yang Huang to Yin Huang transformation of a most fundamental, but also the ultimate cause. The pathogenesis of yinhuang is the transformation of dampness from cold, the failure to treat yanghuang, prolonged or excessive consumption of bitter and cold medicines or weakness of the body, eventually leading to the spleen yang is not invigorated, the transport and transformation of the failure to do its job and lead to cold and dampness stagnation of yinhuang.
3. There is a special stage between Yang Huang and Yin Huang progressively – Yin Yang Huang stage
In our clinical study, we applied the cohort study method to observe the clinical characteristics of 151 cases of chronic heavy hepatitis with different jaundice, and the results showed that 48 patients (31.8%) could not be completely identified with yang and yin yellowness, and the clinical manifestations were jaundice that did not subside for a long time, ineffective treatment with clearing heat and dampness or cooling blood and resolving blood stasis, dull face, abdominal distension, especially after eating, and a pale tongue with white fur or teeth marks, which could be identified as yin yellowness. However, the patient has a slightly dry mouth, or slightly yellow or greasy coating, and also has the manifestation of stasis-heat or damp-heat, the evidence is a mixture of deficiency and reality, which neither belongs to Yang Huang, nor fully meets the diagnostic criteria of Yin Huang. It is the intermediate stage of the progression from Yang Huang to Yin Huang. If these patients are treated correctly and in time, their condition can be expected to change to Yang Huang, but if not, they will develop to Yin Huang and have a poor prognosis.
4, the proportion of contemporary non-yang-yang evidence (yin-yang yellow, yin-yang yellow evidence) has increased significantly, and more attention should be paid to the treatment of this type of patients
Unlike the previous jaundice to Yang yellow, the proportion of contemporary yin yellow, yin-yang yellow evidence increased significantly, the analysis of its causes are mainly the following.
(1) The incidence of acute hepatitis has decreased significantly. Unlike hundreds of years ago or even more than a decade ago, the spectrum of liver diseases has changed significantly, and the incidence of acute hepatitis has decreased significantly, and these patients often have a short duration of illness, with a predominance of yang-yellow evidence;
(2) Chronic heavy hepatitis occurs mostly on the basis of cirrhosis and has a longer course, which can easily lead to jaundice that is prolonged and develops into non-yellowing evidence;
(3) cirrhotic patients have a history of long-term medication, often leading to damage to the spleen and stomach and lead to spleen and stomach deficiency, resulting in the occurrence of non-yang yellow evidence.
5, ignoring the existence of yin and yang yellow evidence hinders the treatment of jaundice
(1) Failure to cover all jaundice, resulting in confusion in the classification of jaundice identification and the existence of a vacuum
As mentioned earlier, yin and yang yellowness is the intermediate stage of the gradual change from yang to yin yellowness, such yang in yin, yin in yang, cold, heat, moisture, stasis, deficiency, reality, light and heavy mixed symptoms, it is difficult to generalize with yang yellowness and yin yellowness to summarize, such as ignoring the different nature of jaundice, will certainly lead to part of the jaundice patient classification or in yang yellowness or in yin yellowness or outside of these two types of evidence, and can not be correctly identified and treated. For this phenomenon of inconsistency between “symptoms” and “evidence”, some scholars have proposed that “the pulse should be taken from the symptoms” or “the symptoms should be taken from the pulse”. Some scholars have proposed the concept of “jaundice” in addition to Yang Huang and Yin Huang, but there is no in-depth study to form a system of diagnosis and treatment; Some scholars have even suggested that “jaundice does not need to be divided into yin and yang” because “the TCM division of jaundice into yin and yang yellowness already seems to have little clinical guidance significance”.
(2) Excessive use of bitter-cold or cold drugs accelerates the transformation of jaundice into yin-yang
If the patient only sees the manifestation of stasis-heat or damp-heat and misidentifies this stage as yang-yellow and repeatedly puts in a large amount of bitter-cold medicine, it is easy to injure yang and defeat the stomach, resulting in the transformation of dampness from yin to yin-yellow and accelerating the transformation of jaundice to yin-yellow, so that the cold and dampness are deeper and deeper, resulting in the patient’s terminal illness.
(3) When the warm method is used but dare not use it, the jaundice is not reversed to yang yellow in time
In the yin-yang yellow stage, Yang Qi is injured, if the appropriate amount of warming drugs are applied to protect Yang Qi and prevent its transmission, the condition can be reversed to Yang Yellow. But ignore the existence of yin and yang yellow, overemphasize the tongue light, the moss is not yellow, the mouth is not thirsty and other symptoms are available, and start to use the rule of warming the yang and dampness, miss the timing of treatment, resulting in the disease can not be cured.
Second, yin and yang yellow evidence identification and treatment
1, yin in yang, yin in yang for its clinical manifestations
Yin and Yang yellow card is the intermediate stage of the gradual change of Yang yellow to Yin yellow, these patients, with jaundice yellow obscure, light or fat tongue or see teeth marks and other manifestations of Yin yellow card, some patients have dry mouth or mouth bitter, light yellow tongue coating and other manifestations of Yang yellow card, manifestation of Yang in Yin, Yin in Yang, evidence of deficiency mixed, the main points of clinical performance are.
① yellow color is obscure or distinct or neither of them is obvious;
②Tongue is pale and/or fat, or with teeth marks;
③White or white greasy tongue coating, or light yellow greasy tongue coating;
④There may be slight dryness and/or bitterness of the mouth;
⑤ fullness with little food.
2. Deficiency of spleen-yang with dampness and turbidity or damp-heat as the disease mechanism
The “Jin Kui Yao – jaundice” cloud: “yellow family, from the wet to get”, a statement expressing the basic pathological factors of jaundice, but jaundice and dampness are most closely related, wet for the yin evil, cause disease easy to block the qi, injury to the Yang Qi. The spleen is damp and therefore likes to be dry and is malodorous. The pathological properties of jaundice are therefore closely related to the strength and weakness of the spleen yang. Patients feel dampness and hurt the spleen and yang, or over-eating cold, or long-term excessive drinking, and cold directly hurt the spleen and stomach, both spleen deficiency, and dampness or damp heat, plus the use of bitter cold for a long time, will hurt yang, so the spleen and yang deficiency and dampness or damp heat for yang-yin yellow pathogenesis.
3.Warm Yang and strengthen the spleen as the treatment rule
Deficiency of spleen yang and dampness or dampness-heat is the pathogenesis of yang-yin-yellow, and there is deficiency of spleen yang in patients with yin-yang-yellow, so warming yang and strengthening spleen is the root of it, and the method of warming cold and dampness or clearing heat and dampness or cooling blood and detoxifying can obviously improve clinical efficacy.
(1) theoretical basis: the Northern Song Dynasty Zhu humerus in the “typhoid fever class evidence of living people book” said: “sun disease, all over the pain, fever, body as smoked yellow, this name in the wet also ….. Art and Annexation Soup …… Most of the dampness, not the sophora, gui, art, can not go also”; “Ming Medical Guide – Volume 4 – jaundice five” pointed out: “….. Although the cloud of dampness and heat, not pure cold, must be accompanied by sweet warm, the gentleman with the penetration of dampness, it is easy to remove the wet, easy to solve the heat, the disease heals itself. If purely cold, heavy injury to the spleen and earth, wet may not be removed, heat may not go, but become abdominal distension carry on.” Although the discussion is about damp-heat jaundice, still do not forget the “sweet and warm” method, we can understand that jaundice is damp-heat, we must pay attention to the protection and support of Yang Qi. The use of warm method in a school of bitter cold clearing medicine discretionary addition of warming drugs to dispel dampness, with a small amount of such as sliced atractylodes, white atractylodes, etc., not only to prevent bitter cold swelling the stomach, but also help to regulate the dampness, warming the meridians, so that the Yang invigorates, the meridians of Qi smooth, then the wet go and heat is not attached. For the initial damp-heat, but too much diarrhea, damage to the Yang, internal heat to cold Yang Huang, more because of adhering to Zhongjing “to cold and damp in seeking” the meaning of.
(2) Practice basis: In our department, the efficiency of the treatment of chronic heavy hepatitis with yin-yang yellowness by the method of warming the yang and strengthening the spleen, cooling the blood and detoxifying the toxin with the addition and subtraction of Yin Chen Jie Fu Tang and Detoxification and Removal of Stasis Tang was 90.5%, which was significantly higher than the traditional method of identification. The safety of the warm-yang method was also good.
We proposed the name and diagnostic criteria of “yin-yang yellowness” for the first time in China, and systematically conducted clinical research on the early intervention of the warm method in the treatment of yin-yang yellowness and yang-yellowness with damp-heat in chronic heavy hepatitis, and established the identification and treatment of “yang-yellowness-yin-yellowness” in chronic heavy hepatitis. The clinical study was conducted to establish the “yang-yang-yang-yang-yin-yang-yin-yang” model of treatment for chronic heavy hepatitis. At present, the early intervention of warming Yang and strengthening the spleen method in the treatment of chronic heavy hepatitis has been adopted as one of the treatment rules in the national “Eleventh Five-Year Plan” science and technology major special project – “Research on the pattern of chronic heavy hepatitis symptoms and the combined Chinese and Western medicine treatment plan”. If validated in a multicenter, randomized, large sample, controlled trial, the jaundice theory of yin-yang-yellow will be further affirmed and promoted. In the future, we will strengthen the theoretical and clinical research work related to the theory of jaundice yin-yang-yang-yang, and work to improve the system of diagnosis and treatment of jaundice in Chinese medicine.